The Problems of Not-So-Primary Care

Medicine has changed. It used to be that physicians made house calls. That is now as rare as finding a 78-inch record in a music store (if you can find a music store). However, we still mistakenly believe that, if we have a medical emergency, we shall be able to see our primary care physician quickly. Unfortunately, given the current state of health care financing, this is not the case in most areas.

Reimbursement for physicians has changed significantly. In the past, physicians were able to be responsible for the care of approximately 3,000 patients and be able to support themselves. Physicians supplemented the income they received for taking care of their patients with revenue from imaging and office procedures, lab tests, and other services (like botox and supplements). Recent legislative policy changes have significantly decreased reimbursement for these ancillary services, however, causing a significant increase in the number of patients physicians must care for.

To see more patients, primary care physicians must manage their schedules carefully to minimize empty appointment slots (and lost revenue). This necessitates double and even triple booking in some cases to ensure that none of the physician’s time goes unused. As a result, our wait once we get to the doctor’s office will be longer.

Another effect is that it will be very difficult to fit in emergencies. If there are already two or three patients scheduled for one appointment time, it is hard to add yet another patient who you know is going to arrive. When I recently had a medical emergency, I was unable to secure an appointment quickly despite my being in the industry for more than 20 years and having been with my physician for 10 years. I was given two options: come in nine days later or go to an urgent care center. If I have a primary care physician, why should I go to an urgent care center or see another physician where they do not have my medical history?

The solution to this, for people with means, is to join a concierge practice. These practices have an annual fee that allows the physician to significantly reduce the number of patients they care for and provide easy access up to and including home visits. The cost for this can range from about $2,000 per year to as much as $10,000 per year. However, this is not affordable for most and will only exacerbate our impressions of a two-tiered health care system.

We need to make a decision. Do we continue with the current system and evolve to a system of nurse practitioners and concierge medicine, or do we pay primary care physicians well enough to choose primary care as a career and allow them to take care of a reasonable number of patients to ensure timely access to care?